How to Turn Downtime Into Offers

New federally financed drug research reveals a stark
disparity: children covered by Medicaid are given powerful antipsychotic
medicines at a rate four times higher than children whose parents have private
insurance. And the Medicaid children are more likely to receive the drugs for
less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are
almost certain to add fuel to a long-running debate. Do too many children from
poor families receive powerful psychiatric drugs not because they actually need
them — but because it is deemed the most efficient and cost-effective way to
control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on
Medicaid children, serious as that may be. Antipsychotic drugs can also have
severe physical side effects, causing drastic weight gain and metabolic changes
resulting in lifelong physical problems.

On Tuesday, a pediatric advisory committee to the Food
and Drug Administration met to discuss the health risks for all children who
take antipsychotics. The panel will consider recommending new label warnings for
the drugs, which are now used by an estimated 300,000 people under age 18 in
this country, counting both Medicaid patients and those with private insurance.

Meanwhile, a group of Medicaid medical directors from 16
states, under a project they call Too Many, Too Much, Too Young, has been
experimenting with ways to reduce prescriptions of antipsychotic drugs among
Medicaid children.

They plan to publish a report early next year.

The Rutgers-Columbia study will also be published early
next year, in the peer-reviewed journal Health Affairs. But the findings have
already been posted on the Web, setting off discussion among experts who treat
and study troubled young people.

Some experts say they are stunned by the disparity in
prescribing patterns. But others say it reinforces previous indications, and
their own experience, that children with diagnoses of mental or emotional
problems in low-income families are more likely to be given drugs than receive
family counseling or psychotherapy.

“It’s easier for patients, and it’s easier for docs,”
said Dr. Derek H. Suite, a psychiatrist in the Bronx whose pediatric cases
include children and adolescents covered by Medicaid and who sometimes
prescribes antipsychotics. “But the question is, ‘What are you prescribing it
for?’ That’s where it gets a little fuzzy.”

Too often, Dr. Suite said, he sees young Medicaid
patients to whom other doctors have given antipsychotics that the patients do
not seem to need. Recently, for example, he met with a 15-year-old girl. She had
stopped taking the antipsychotic medication that had been prescribed for her
after a single examination, paid for by Medicaid, at a clinic where she received
a diagnosis of bipolar disorder.

Why did she stop? Dr. Suite asked. “I can control my
moods,” the girl said softly.

After evaluating her, Dr. Suite decided she was right.
The girl had arguments with her mother and stepfather and some insomnia. But she
was a good student and certainly not bipolar, in Dr. Suite’s opinion.

“Normal teenager,” Dr. Suite said, nodding. “No scripts
for you.”

Because there can be long waits to see the psychiatrists
accepting Medicaid, it is often a pediatrician or family doctor who prescribes
an antipsychotic to a Medicaid patient — whether because the parent wants it or
the doctor believes there are few other options.

Some experts even say Medicaid may provide better care
for children than many covered by private insurance because the drugs — which
can cost $400 a month — are provided free to patients, and families do not have
to worry about the co-payments and other insurance restrictions.

“Maybe Medicaid kids are getting better treatment,” said
Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook
School of Medicine. “If it helps keep them in school, maybe it’s not so
bad.”

In any case, as Congress works on health care legislation
that could expand the nation’s Medicaid rolls by 15 million people — a 43
percent increase — the scope of the antipsychotics problem, and the expense,
could grow in coming years.

Even though the drugs are typically cheaper than
long-term therapy, they are the single biggest drug expenditure for Medicaid,
costing the program $7.9 billion in 2006, the most recent year for which the
data is available.

The Rutgers-Columbia research, based on millions of
Medicaid and private insurance claims, is the most extensive analysis of its
type yet on children’s antipsychotic drug use. It examined records for children
in seven big states — including New York, Texas and California — selected to be
representative of the nation’s Medicaid population, for the years 2001 and 2004.

The data indicated that more than 4 percent of patients
ages 6 to 17 in Medicaid fee-for-service programs received antipsychotic drugs,
compared with less than 1 percent of privately insured children and adolescents.
More recent data through 2007 indicates that the disparity has remained, said
Stephen Crystal, a Rutgers professor who led the study. Experts generally agree
that some characteristics of the Medicaid population may contribute to
psychological problems or psychiatric disorders. They include the stresses of
poverty, single-parent homes, poorer schools, lack of access to preventive care
and the fact that the Medicaid rolls include many adults who are themselves
mentally ill.

As a result, studies have found that children in
low-income families may have a higher rate of mental health problems — perhaps
two to one — compared with children in better-off families. But that still does
not explain the four-to-one disparity in prescribing antipsychotics.

Professor Crystal, who is the director of the Center for
Pharmacotherapy at Rutgers, says his team’s data also indicates that poorer
children are more likely to receive antipsychotics for less serious conditions
than would typically prompt a prescription for a middle-class child.

But Professor Crystal said he did not have clear evidence
to form an opinion on whether or not children on Medicaid were being
overtreated.

“Medicaid kids are subject to a lot of stresses that lead
to behavior issues which can be hard to distinguish from more serious
psychiatric conditions,” he said. “It’s very hard to pin down.”

And yet Dr. Mark Olfson, a psychiatry professor at
Columbia and a co-author of the study, said at least one thing was clear: “A lot
of these kids are not getting other mental health services.”

The F.D.A. has approved antipsychotic drugs for children
specifically to treat schizophrenia, autism and bipolar disorder. But they are
more frequently prescribed to children for other, less extreme conditions,
including attention deficit hyperactivity disorder, aggression, persistent
defiance or other so-called conduct disorders — especially when the children are
covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for
these “off label” uses, there have been no long-term studies of their effects
when used for such conditions.

The Rutgers-Columbia study found that Medicaid children
were more likely than those with private insurance to be given the drugs for
off-label uses like A.D.H.D. and conduct disorders. The privately insured
children, in turn, were more likely than their Medicaid counterparts to receive
the drugs for F.D.A.-approved uses like bipolar disorder.

Even if parents enrolled in Medicaid may be reluctant to
put their children on drugs, some come to rely on them as the only thing that
helps.